HIGHLY PRIORITIZED: Rehydration, to restore fluid volume and correcting any electrolyte imbalances Nursing Problem: Diarrhea, Vomiting

Nursing Diagnosis: Deficient fluid volume related to active fluid loss ( diarrhea and vomiting) Subjective/ Objective Related Labs and Short Term Goal Interventions Cues Related Durgs Subjective Cues: Related Labs: After 8 hrs. of duty and 1.)Determine the effects of age. 5 beses akong nagtae Chemistry appropriate nursing @ 6 na beses ding Hematology care interventions, the nagsuka kagabi, mula Urinalysis patient will be able to 2.)Compare usual and current weight 11pm hanggang 1:17am Parasitology maintain the fluid 3.)Advice intake of foods with high fluid kaya dumeretso na volume at functional content kami dito . As Related Drugs: level by: 4.)Measure client s output verbalized by the IVF of 1L LR 5.)Encourage change in position frequently patient. fluid replacement 1.)Note physical signs associated with 6.)Provide optimal skin care Ciprofloxacin 2x/day Objective Cues: dehydration. 7.)Provide frequent oral and eye care 500mg 1cap -dry skin and dry lips 2.)Establish 8 hrs. fluid 8.)Discuss factors and ways to prevent -Antibiotic to treat -body malaise replacement, needs, dehydration Bacterial infections -paleness and routes, as ordered. 9.)Assist client to measure her own intake and Dupatadin 3x/day 10g -restlessness 3.)Promote comfort and output 1tab V/S: safety of the patient 10.)Recommend restriction of caffeine and -Abd. pain T- 36.6 C 4.)Promote wellness alcohol Plasil 10mg 3x/day for P- 73 bpm 5.)Health teaching on 10days R- 21 cpm patient on how to attain DEPENDENT -ant- emetic BP- 1400/90 mmHg normal hydration 11.)Administer IV fluids as Indicated Pantoloc 40g 1x/day for status. 5days 6.)Maintain normal -anti-ulcer fluid volume and 12.)Administer medications as ordered Hydrase 2x/day for 5 replace fluid loss. days 13.)Review laboratory data 14.)Giving advice on the patient to increase fluid intake. 15.)Encourage increase oral fluid intake

Rationale -Elderly individuals are at high risk because of decreasing response/ effectiveness of compensatory mechanism -Indicator of overall fluid nutritional status -To provide hydration -To ensure accurate data of fluid status -To prevent stasis and reduce risk of tissue injury -To prevent injury from Dryness -To prevent injury from Dryness -To educate the patient -Help determine baseline symptoms -To prevent frequent Urination

Evaluation Goal was met. After 8 hrs. of duty and appropriate nursing care interventions, the patient was able to maintain her fluid volume in functional level as evidenced by: 1.)Physical signs associated with dehydration is noted and examined 2.)Establish 8 hrs. fluid replacement, needs, as ordered 3.)Comfort and safety of the patient was promoted 4.)Wellness promoted 5.)The patient demonstrated proper understanding on the health teaching 6.)Fluid volume was improved and maintained

-Fluids may be given in this manner, if client is unable to take oral fluid, or when rapid fluid resuscitation is required. -Antiemetics or antidiarrheals limit gastric/ intestinal losses -To evaluate degree of fluid and electrolyte imbalance and response to therapist -To promote understanding and avoid reoccurrence of Illness -To reduce risk of skin breakdown

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